Level: Foundational
Difficulty: Easy
Subtopic: Anxiety disorders
NCLEX: A 42-year-old client in a crisis stabilization unit is being evaluated for panic symptoms. Assessment data includ…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 42-year-old client in a crisis stabilization unit is being evaluated for panic symptoms. Assessment data include the client has not slept in 3 days and speech is rapid and pressured. Which nursing action is the priority to keep the client safe?
Question
A. Leave the client alone to promote independence while finishing charting.
B. Apply the first intervention in the policy manual without a current assessment.
C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
D. Wait for the provider's routine visit before acting on abnormal findings.
B. Apply the first intervention in the policy manual without a current assessment.
C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
D. Wait for the provider's routine visit before acting on abnormal findings.
Rationale
Correct answer: C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.